Therapeutic communities (TCs) for addictions are drug-free environments in which people with addictive problems live together in an organized and structured way to promote change toward recovery and reinsertion in society. Despite a long research tradition in TCs, the evidence base for the effectiveness of TCs is limited according to available reviews. Since most of these studies applied a selective focus, we made a comprehensive systematic review of all controlled studies that compared the effectiveness of TCs for addictions with that of a control condition. The focus of this paper is on recovery, including attention for various life domains and a longitudinal scope. We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope. Our search strategy revealed 997 hits. Eventually, 30 publications were selected for this paper, which were based on 16 original studies. Two out of three studies showed significantly better substance use and legal outcomes among TC participants, and five studies found superior employment and psychological functioning. Length of stay in treatment and participation in subsequent aftercare were consistent predictors of recovery status. We conclude that TCs can promote change regarding various outcome categories. Since recovering addicts often cycle between abstinence and relapse, a continuing care approach is advisable, including assessment of multiple and subjective outcome indicators.
Drug addiction is a complex mental health problem that is often associated with difficulties in various life domains such as unemployment, homelessness, relational conflicts, problems with the courts, and psychiatric comorbidity [
A wide range of treatment and support services are available for persons with alcohol or drug addiction problems: detox programs, drug-free outpatient treatment, methadone maintenance therapy, long-term residential treatment programs, and harm reduction services. Therapeutic communities (TCs) for addictions, also called drug-free or concept TCs, aim at the reinsertion into society of former drug addicts and were one of the first specialized treatment initiatives for individuals with addiction problems, that evolved outside—and often in reaction to—the traditional mental health care. The TC history dates back to Synanon, a self-supporting community of ex-addicts founded in 1958 in Santa Monica (California) [
Although outpatient, medically-assisted (substitution) therapy is currently the most common addiction treatment modality [
Despite a long research tradition in TCs [
Since sound scientific evidence is needed to inform service users, treatment providers, and policy makers about TCs’ potential to promote recovery, the aim of this paper is to review the effectiveness of TCs for addictions, based on a comprehensive systematic review of available randomized and nonrandomized controlled studies. The paper is limited to studies with a controlled design, as these are robust study designs that generate a high level of evidence. Also, nonrandomized studies were included, since the number of randomized studies was very small (
This narrative review focuses on controlled studies (randomized trials as well as quasi-experimental designs) of therapeutic communities for addictions. We opted for a narrative review instead of a meta-analysis, given the heterogeneity of the study methodologies and the variety in data reporting. Studies were eligible if they met the following inclusion criteria. Intervention: therapeutic communities for the treatment of drug addiction that are long-term hierarchically structured (residential) educational environments, where former drug users live together and work towards recovery, and which are based on self-help and mutual help principles [ Target population: adults addicted to illegal drugs (mostly heroin, cocaine, or amphetamines), often in combination with an addiction to other (legal) substances (e.g., alcohol, prescription drugs). Studies including persons with comorbid psychiatric disorders were eligible, if all study participants had a drug addiction. Outcome measures: at least one of the following (nonexhaustive) list of outcome measures was reported: substance use (illicit drug use, alcohol use), length of stay in treatment (retention, treatment completion/drop-out), employment status, criminal involvement, health and well being, family relations, quality of life, treatment status, mortality, and so forth. Objective (describing the actual situation) and subjective (indicating individuals’ personal perspective) indicators were considered, as well as self-report measures, biological markers, and administrative data. Study design: randomized controlled trials and quasi-experimental studies that have compared prospectively residents that followed TC treatment with a control group that was treated in a usual care setting (“treatment as usual”/standard of care) or another type of TC (e.g., shorter program/day TC) or with a control group out of treatment (e.g., in prison/waitlist controls). Studies needed to report findings on TC outcomes separately from these of other types of interventions (e.g., aftercare).
Available reviews and meta-analyses were not included, but all studies selected for the reviews were screened based on the aforementioned inclusion criteria. Studies that did not focus on TC treatment, but on another type of residential care, were excluded from the paper. If several publications concerned the same baseline sample and study design, these publications were regarded as one single study.
We searched the following databases: ISI Web of Knowledge (WoS), PubMed, and DrugScope, up to December 31, 2011. There were no language, country, or publication year restrictions. Search strategies were developed for each database, based on the search strategy developed for ISI Web of Knowledge, but were revised accordingly to take into account differences in controlled vocabulary and syntax rules. The key words we searched for were “therapeutic communit*” AND “drug* or addict* or dependen* or substance use” AND “outcome* or evaluation or follow-up or effectiveness.” The reference lists of retrieved studies and of available reviews were checked for relevant studies. In addition, the index of the International Journal of Therapeutic Communities, a specialized peer-reviewed journal on therapeutic communities and other supportive organisations, was screened for relevant publications.
Our search strategy revealed 997 hits, which resulted in a first selection of 185 records, based on title and abstract (see Figure
Flowchart of the search process and number of studies retained/excluded in each phase.
In addition to the database search, conference abstracts of European Federation of Therapeutic Communities (EFTC), World Federation of Therapeutic Communities (WFTC), and European Working Group on Drugs Oriented Research (EWODOR) conferences and the grey literature were scanned for relevant (un)published studies. We made a search of the registry of ongoing clinical trials to identify any ongoing RCTs. In case a publication could not be tracked through the Ghent University online library system, the study authors were contacted for a copy of the original manuscript. Finally, TC experts in various countries as well as the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) national focal points were contacted to retrieve additional (un)published or ongoing studies that have assessed the effectiveness of TCs for addictions.
In total, 46 controlled studies were identified (28 based on the previously mentioned search strategy and 18 additional titles were selected based on the reference lists of selected studies and available reviews). After reading the full texts of these articles, 16 studies were excluded, because only in-treatment outcomes were reported (
Two reviewers (Mieke Autrique and Wouter Vanderplasschen) extracted data on the characteristics and results from the selected studies into a large summary table (cf. Table
Overview of included studies (
Authors | Study design + measurement(s) | Participants | Intervention + comparison group | Outcome measures |
Correlates of relapse/abstinence | ||||
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Retention | Substance use | Crim activity | Employment | Other | |||||
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(1) Sacks et al., 2012 |
Prospective controlled study design (partial randomisation, since assignment ratio changed during the study) |
127 male offenders with substance use and mental disorders who participated in various types of prison Tx |
Reentry MTC ( |
SR drug offences: 37 versus 58%*; reincarc. rate: 19 versus 38%* |
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(2) Zhang et al., |
Prospective controlled study design (QES) |
798 male offenders with documented history of substance abuse |
Prison-based TC ( |
1 year FU |
Rearrests: 54.0 versus 47.6% (ns); reincarc.: 54.7 versus 51.9% (ns); days in prison: 79.1 versus 77.4 | Participation in aftercare mediated reincarc. rates (after 1 year (ns), not after 5 years) and time in prison (after 1* and 5 years (ns)) | |||
5 year FU | Rearrests: 80.4 versus 78.2% (ns); reincarc: 72.4 versus 72.5% (ns); days in prison: 450.4 versus 412.7 | ||||||||
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(3) Messina et al., 2010 (California, USA) [ |
Prospective randomised controlled study design |
115 female offenders with documented history of substance abuse |
Gender-responsive MTC in prison ( |
Months in aftercare: 2.6 versus 1.8* |
No |
No |
No |
Greater reduction in drug use among MTC group*, when controlling for race, employ. + marital status | |
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(4) Welsh, 2007 |
Prospective controlled study design (QES in 5 state prisons) |
708 male inmates admitted to drug Tx in prison |
5 prison TCs ( |
No |
Lower reincarc and rearrest rates, respectively 30 and 24% versus 41 and 34%* |
Higher employ.: 39.2 versus 25.9%*** | Reincarc. predicted by post-release employment status | ||
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(5) Sullivan et al., 2007 (Colorado, USA) [ |
Prospective randomized controlled study design |
139 male inmates with substance use and other psychiatric disorders |
Prison MTC ( |
Rates of any substance use: 31 versus 56%**; any illicit drug use: 25 versus 44%*; alcohol intox.: 21 versus 39%* |
Sign. association between relapse and committing new (nondrug) offences | ||||
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(5) Sacks et al., 2004 (Colorado, USA) [ |
Prospective controlled study design (no true randomisation, since 51 subjects moved from one condition to another) |
185 male inmates with substance use and other psychiatric disorders |
Prison MTC ( |
Lower reincarc. rates: 9 versus 33%**; no |
MTC aftercare participants had superior outcomes regarding rates of reincarc.*, crim. activity* and drug-related crim activity* compared with controls | ||||
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(6) Morral et al., 2004 (Los Angeles, USA) [ |
Prospective controlled study design (cases assigned by probation) |
449 adolescent probationers with substance abuse problems |
MTC in prison (Phoenix Academy) ( |
No |
Improved substance use outcomes on substance problem index*, density index*, and involvement scale* | Greater, nonsign. declines on various measures of crim involvement | Greater reduction of somatic** and anxiety* symptoms + sign. larger reductions in psychological symptoms between 3 and 12 month FU | ||
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(7) Inciardi et al., 2004 (Delaware, USA) [ |
Prospective controlled study design (group assignment by correctional staff) Outcomes 42 and 60 months after baseline | 690 male inmates with substance abuse problems, eligible for work release |
Work-release (transitional) TC ( |
TC participation strongest predictor of drug-free status after 42 (OR 4.49***) and 60 months (OR 3.54***) | TC participation strongest predictor of absence of rearrest after 42 (OR 1.71**) and 60 months (OR 1.61*) | Older age predicted drug-free** and no rearrest status***, while frequency of prior drug use predicted relapse** after 48 months | |||
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While greater exposure to TC Tx led to better outcomes after 1 year, at 3 years after discharge no | ||
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(7) Lockwood et al., 1997 (Delaware, USA) [ |
Prospective controlled study design |
483 inmates with history of substance abuse |
Transitional TC (CREST) ( |
87% drug-free, versus 71% in KEY, 73.7% in work release and 93.3% in KEY-CREST group | 86.5% no arrest, versus 75% in KEY, 59.9% in work release and 97.1% in KEY-CREST group | ||||
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(7) Nielsen et al., 1996 (Delaware, USA) [ |
Prospective controlled study design (QES) |
689 inmates with history of substance abuse |
Transitional TC (CREST) ( |
Sign. lower relapse after 6 (16.2 versus 62.2)*** and 18 months (51.7 versus 79%)*** | Sign. lower recidivism after 6 (14.7 versus 35.4)*** and 18 months (38.2 versus 63%)*** | Age, race, and gender do not affect outcomes, but length of time in program reduced relapse and recidivism rates (ns) | |||
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(7) Martin et al., 1995 (Delaware, USA) [ |
Prospective controlled study design (QES) |
483 inmates with history of substance abuse |
Transitional TC (CREST) ( |
Probability of being drug free the highest among CREST (0.84)*** and KEY + CREST group (0.94)*** | Prob. of being arrest free the highest among CREST (0.86)*** and KEY + CREST group (0.97)*** | Prob. of no longer injecting the highest in CREST (0.97)*** and KEY + CREST group (0.97) | No | ||
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(8) Prendergast et al., 2004 (California, USA) [ |
Prospective randomized controlled study design |
715 male inmates with substance abuse problems |
Amity prison TC ( |
Months receiving Tx post-release: 4.6 versus 1.7*** | Heavy drug use past year: 24.9 versus 22.6% | Reincarcerated within 5 years: 75.7 versus 83.4%* |
Stable job in past year: 54.8 versus 52.3% | Psychologic. distress: 31.8 versus 44.6 | Reincarc. predicted by younger age* and fewer months in Tx after release*** |
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(8) Prendergast et al., 2003 (California, USA) [ |
Prospective randomized controlled study |
715 male inmates with substance abuse problems |
Amity prison TC ( |
Longer time to first drug use: 77 versus 31 days*** |
1 year reincarc. rate: 33.9 versus 49.7%*; more days to first illegal act. (138 versus 71 days)***; no |
Participation in Tx associated with more days to reincarc. | |||
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(8) Wexler et al., 1999 (California, USA) [ |
Prospective randomised controlled study design |
715 male inmates who volunteered for TC treatment in prison |
Amity prison TC ( |
Lower reincarc rates after 12 (33.9 versus 49.7%)*** and 24 months (43.3 versus 67.1%)*** |
Reincarc. rates sign lower after 12 and 24 months among TC + aftercare completers, as opposed to persons who dropped out previously | ||||
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(9) Greenwood et al., 2001 (San Francisco, USA) |
Prospective controlled study design (only partial randomisation, since sign. drop-out among control before Tx start) |
261 substance abusers seeking treatment at Walden House |
Residential TC ( |
Time in program: 109.8 versus 102.7 days | Total abstinence after 6 (62.6 versus 47%), 12 (47.9 versus 49%) and 18 months (50.4 versus 55.2%) |
Relapse after 18 months predicted by employment status prior to Tx start***, injecting drug use** and having >1 sexual partner** | |||
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(9) Guydish et al. 1999 (San Francisco, USA) |
Prospective controlled study design (only partial randomisation, since sign. drop-out among controls before Tx start) |
188 substance abusers seeking treatment at Walden House who participated in all 3 FU-interviews |
Residential TC ( |
No |
Lower SCL scores at 6**, 12*, and 18* months, lower BDI scores after 12 months*, higher social support scores at 18 months*; lower social problem severity (ASI)* | Most changes observed during first months of Tx, followed by maintenance of change | |||
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(9) Guydish et al. 1998 (San Francisco, USA) |
Prospective controlled study design (only partial randomisation) |
261 substance abusers starting treatment at Walden House |
Residential TC ( |
Tx adherence after 6 months: 29 versus 34% in day TC; |
Lower ASI severity scores for social* and psychological problems** | Persons who stayed >6 months in Tx had sign lower legal, alcohol, drug, and social severity scores | |||
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(10) Nemes et al. 1999 (Washington, USA) [ |
Prospective, randomised controlled study design |
412 substance users seeking Tx at a central intake unit |
Standard TC ( |
Completion rates: 33 versus 38% (ns), and similar time in Tx (8.2 versus 8.6 months) | Lower SR heroin use: 9 versus 15%* | Lower rearrest rates: 17 versus 26%** + longer time to arrest (9.4 versus 6.9 months)* | Employment rate higher in standard TC: 72 versus 56%** | Lower heroin and cocaine use levels + lower rearrest rates among treatment completers versus noncompleters | |
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(11) De Leon et al., 2000 (New York, USA) [ |
Prospective controlled study design (QES: sequential group assignment) |
342 homeless mentally ill substance abusers |
MTC1 for homeless persons ( |
12 months | MTC2 had less alcohol intox* + fewer illegal drug use** + used less substances** than TAU |
No |
MTC1*** and MTC2*** more likely to be employed than TAU | No |
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24 months | MTC2 had less alcohol intox* + used less substances* compared with TAU |
MTC1* and MTC2*** committed fewer crimes than TAU | MTC1** and MTC2*** more likely to be employed than TAU | MTC2 had less symptoms of depression*** and anxiety* than TAU | MTC2 improved more on several outcomes measures than MTC1 | ||||
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(11) French et al., 1999 (New York, USA) [ |
Prospective controlled study design (QES: sequential group assignment) |
342 homeless mentally ill substance abusers |
MTC for homeless persons ( |
No |
Fewer criminal activity** | Better employm. outcomes (ns) | Lower scores on BDI*, no |
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(12) Nuttbrock et al., 1998 (New York, USA) [ |
Prospective controlled study design (QES, as allocation based on availability + client preference) |
290 homeless men with major mental disorder and history of substance abuse |
Modified TC ( |
43% stayed 6 months in TC (versus 55%); 25% stayed 12 months (versus 37%) | 4.1 versus 30.1% pos. urine tests*; SR alcohol use: 0 versus 14.3%*; SR marijuana use: 2.6 versus 2.9%; SR crack use: 7.7 versus 14.2* | Greater (ns) reductions in psycho-pathology (depression, anxiety, psychiatric distress) MTC participation predicted lower levels of anxiety** and better GAF-scores** | Drop-out after 6–12 months in community residences was predicted by substance use severity* | ||
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(13) McCusker et al. 1997 (New England, USA) |
Prospective controlled study design (no real randomisation, since |
539 drug abusers entering residential Tx at 2 sites |
Traditional TC program (6 ( |
Tx completion: 23% in long TC, 34% in shorter TC, 31% in long MTC and 56% in short MTC | Time to drug use not |
Stronger effect of long TC versus short TC and MTCs regarding legal problems | Effect of TC on employm. stronger than in MTC* | Small effects of long TC versus short TC and MTCs regard. other ASI domains | |
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(13) McCusker et al., 1996 (Massachusetts, USA) [ |
Prospective randomized controlled study design |
444 drug abusers entering one residential Tx facility |
Long MTC ( |
Program completion: 30 versus 56% in short TC program | Relapse to drug use in first week after leaving Tx: 33 versus 70%* |
Greater improvement in levels of depression among persons staying >80 days in TC*** | |||
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(13) McCusker et al., 1995 (New England, USA) |
Prospective controlled study design |
628 drug abusers entering residential Tx at 2 sites |
Traditional TC program (6 ( |
40 day retention: respectively, 70, 85, 73, and 72%; Tx completion: respectively, 33, 21, 56, 30% (ns |
Relapse: 50% in TC versus 44% in MTC |
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(14) Hartmann et al. 1997 (Missouri, USA) [ |
Controlled study design (QES, self-selection for exp. intervention) |
286 male offenders with a history of substance abuse |
Prison TC graduates ( |
No substance abuse: 67.4 versus 62% (ns) | No arrest: 85.4 versus 72%** |
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(15) Bale et al., 1984 (California, USA) [ |
Prospective controlled study design (only partial randomization due to substantial drop-out after group allocation) |
363 male veterans addicted to heroin entering withdrawal Tx |
3 TCs ( |
Mean TIP longer in TC 1 (10.4 weeks) and TC3 (11.5 weeks)* than in TC2 (6.0 weeks) | No heroin use: 40, 48.1, and 35.4% versus 33.3% of controls; |
No conviction: 44*, 32.5 and 59.5%** versus 31.3% of controls | Employed/attending school: 48*, 46.8 and 51.9%** versus 34% of controls | Mortality: 1.7% in TCs versus 6.6% among controls | The 3 TCs differed largely on program characteristics |
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(15) Bale et al., 1980 (California, USA) [ |
Prospective controlled study design (as treated analyses) |
585 male veterans addicted to heroin entering withdrawal Tx |
Veterans staying long (≥50 days) ( |
1-year retention rate: <5% in TC versus 74.5% in MMT | Recent heroin use + any illicit drug use lower in long TC subjects (37.3 and 29.3) than detox only-group (65.5 and 46.9)**, but not than MMT group (46.6 and 38.6%) | Arrest (37.3%), conviction (21.3%) and reincarc (4%) rate sign lower than in detox only-group (54.5**, 38** and 21.1%***, resp.), but not than MMT group (49.2, 22, and 10.2%) | Employm./school attendance: 65.3% of long TC group, 50.9% of MMT and 38.4%*** of detox only-group | Sign. more subjects had good global outcome score in long TC (64%) and MMT (54.45%) versus detox only-group (33.8%) | TC with confrontational style least successful |
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(29) Coombs, 1981 (California, USA) [ |
Prospective controlled study design (group allocation by self-selection) |
207 heroin addicts starting treatment in one of 2 TCs |
Long-term TC ( |
Program completion: 63.6 versus 74.6% | Total abstinence: 4.3 versus 0%; |
Program graduates used less often illicit drugs and were less likely to have relapsed or to be rearrested compared with splittees. Also higher employment rates among graduates |
TC: therapeutic community, MTC: modified therapeutic community; SR: self-reported; QES: quasi-experimental study; Tx: treatment; TIP: time in program; BDI: Beck Depression Inventory; ASI: Addiction Severity Index; level of significance: *
Summary of the findings from the selected studies (
Reference number of the study/studies | Type of TC | Comparison condition | Followup length | Outcome measures |
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Retention | Substance use | Criminal activity | Employment | Health | Family and social relations | ||||
(1) Sacks et al., 2012 [ |
Prison | TAU | 1 year | + | |||||
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(2) Zhang et al., 2011 [ |
Prison | TAU | 1 year | = | |||||
5 years | = | ||||||||
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(3) Messina et al., 2010 [ |
Prison | Other TC | 1 year | + | = | = | = | = | |
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(4) Welsh, 2007 [ |
Prison | TAU | 2 years | = | + | + | |||
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(5) Sullivan et al., 2007 [ |
Prison | TAU | 1 year | + | + | ||||
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(6) Morral et al., 2004 [ |
Prison | TAU | 1 year | = | + | = | + | ||
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(7) Inciardi et al., 2004 [ |
Prison | TAU | 6 months | + | + | + | |||
1 year | + | + | |||||||
3 years | + | = | |||||||
3 years 6 months | + | + | |||||||
5 years | + | + | |||||||
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(8) Prendergast et al., 2004 [ |
Prison | TAU | 1 year | + | + | ||||
2 years | + | ||||||||
5 years | = | = | + | = | = | ||||
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(9) Greenwood et al., 2001 [ |
Community-based | Other TC | 6 months | = | + | + | + | ||
1 year | = | = | + | ||||||
1 year 6 months | = | + | + | ||||||
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(10) Nemes et al., 1999 [ |
Community-based | Other TC | 1 year 6 months | = | + | + | + | ||
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(11) De Leon et al., 2000 [ |
Community-based | TAU | 1 year | + | = | + | = | ||
2 years | + = | + | + = | + | |||||
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(12) Nuttbrock et al., 1998 [ |
Community-based | TAU | 1 year | − | + | + | |||
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(13) McCusker et al., 1997 [ |
Community-based | Other TC | 6 months | = | = | ||||
1 year | − | = | = | + | |||||
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(14) Hartmann et al., 1997 [ |
Prison | TAU | 6 months | = | + | ||||
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(15) Bale et al., 1984 [ |
Community-based | TAU | 1 year | − | + | + | + | + | |
2 years | + | + (illicit) |
+ | + | |||||
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(16) Coombs et al., 1981 [ |
Community-based | Other TC | 1 year | = | + |
TC: Therapeutic Community, Other TC: Other TC modality, TAU: Treatment As Usual.
Based on our review of controlled studies of TC effectiveness, we identified 30 publications that included a longitudinal evaluation of TCs for addictions and applied a prospective controlled study design (cf. Table
The follow-up period in most controlled studies is between 6 and 24 months, and only three studies have followed participants for more than 36 months. Study outcomes may vary according to the follow-up moment [
As opposed to all other outcome categories, TC participants scored worse in comparison with controls on treatment retention/completion. Only two studies showed higher retention rates for the TC group, while three studies found significantly worse completion rates among TC-participants, and six studies found non-significant between group differences, mostly in favor of the control condition (cf. Table
Five out of six studies that have reported employment outcomes found significantly better employment rates among TC participants. Also, five studies (out of 7) showed superior outcomes on psychological symptoms, as compared with controls. Other outcomes that were studied are risk behavior (
Although TC participants had at some point posttreatment better substance use outcomes than controls in 10 studies, substance use levels varied greatly and overall, between 25% and 55% of the respondents relapsed to drug use after 12 to 18 months. Some studies found very low initial relapse rates (e.g., 4% [
The majority of studies found a positive impact of TC treatment on diverse legal outcomes, such as recidivism, rearrest, and reincarceration. Recidivism rates (self-reported criminal involvement) of TC participants after one year are usually around 40%–50% [
Six controlled studies have investigated the outcomes of TC participants in comparison with controls beyond a period of 12 to 18 months (cf. Table
Several studies have identified correlates of relapse and recidivism after TC treatment. Participation in aftercare [
Eleven studies have compared TC treatment with some form of usual care (e.g., case management, standard treatment, and probation), and five studies compared one type of TC with another form of TC treatment (modified versus standard TCs, or short versus long TC programs). In the latter case, the longest/most comprehensive TC program was regarded as the experimental condition, while the shorter/least intensive program was seen as the control condition. Only three comparisons of longer and shorter TC programs yielded significantly better substance use outcomes at the first follow-up moment [
Most controlled studies of TC effectiveness have focused on TCs in prison settings (
This narrative review was based on 16 studies that have evaluated the effectiveness of TCs as compared with other viable interventions regarding various indicators related with recovery: substance use, criminal involvement, employment, psychological well being, and family and social relations. Based on the study findings, we can conclude that there is some evidence for the effectiveness of therapeutic community treatment. Almost two out of three studies have shown significantly better substance use and legal outcomes at the first follow-up moment after treatment among persons who stayed in a TC as compared with controls. Five studies found superior employment outcomes among TC participants, while another five studies showed significantly fewer psychological problems in the experimental group. Only four studies have reported significantly better differential outcomes in at least three outcome categories. This does not mean that TC participants do not improve equally on all life domains, but these outcomes often remained unreported or the observed progress did not differ significantly from that among the control group. Several reviews [
While looking beyond abstinence and desistance is warranted from a recovery perspective [
Treatment in TCs for addictions takes time, usually around 6 to 12 months, which heightens the possibility that residents leave prematurely [
The recovery movement starts from a longitudinal approach to addiction and other mental health problems [
Finally, the study findings show that TC treatment has generated beneficial outcomes in diverse treatment settings and may have particularly strong effects among severely addicted individuals like incarcerated, homeless, and mentally ill drug addicts [
First, most selected studies were published in peer reviewed journals. Although the restriction of peer-review guarantees some form of quality control, it may have induced a selection bias as the likelihood of retrieving non-English language articles was limited in this way. Only results that were reported in the published papers could be included, while it was often unclear whether the nonreporting of some specific outcomes (e.g., recidivism, alcohol use) meant that this information was not collected, not analyzed, or did not yield significant findings. Second, substantial heterogeneity has been observed between the included studies, not only regarding program and setting characteristics, but also regarding sample characteristics and outcome measures. Despite the common “community as method” principle [
Therapeutic communities for addictions can be regarded as recovery-oriented programs that produce change regarding substance use, legal, employment, and psychological well-being outcomes among drug addicts with severe and multiple problems. Despite various methodological constraints, TCs appeared to generate significantly better outcomes in comparison with other viable interventions in two out of three studies. TC programs have usually been evaluated from an acute care perspective with a primary focus on abstinence and recidivism, while a continuing care approach including multiple and more subjective outcome indicators is necessary from a recovery perspective. If residents stay long enough in treatment and participate in subsequent aftercare, TCs can play an important role on the way to recovery. Abstinence may be just one resource to promote employment or enhance personal well being which can in turn contribute to recovering addicts’ participation in community-based activities and their social inclusion.
This study was supported by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (Contract code: CT.11.IBS.057). The authors would like to thank Dr. Teodora Groshkova for her support with this comprehensive review of the outcome literature on TCs for addictions. They are further grateful to Ilse Goethals and Mieke Autrique for their preparatory work for this literature review.